Minimal clinically important differences in the erectile function domain of the International Index of Erectile Function scale

Erectile dysfunction after acetabular fracture

Objectives

To determine the rate of erectile dysfunction in male patients who have sustained an acetabular fracture with no previously identified urogenital injury.

Design

Cross-sectional survey.

Setting

Level 1 Trauma Center.

Patients/Participants

All male patients treated for acetabular fracture without urogenital injury.

Intervention

The International Index of Erectile Function (IIEF), a validated patient-reported outcome measure for male sexual function, was administered to all patients.

Main Outcome Measurements

Patients were asked to complete the International Index of Erectile Function score for both preinjury and current sexual function, and the erectile function (EF) domain was used to quantify the degree of erectile dysfunction. Fractures were classified according the OTA/AO classification schema, fracture classification, injury severity score, race, and treatment details, including surgical approach were collected from the database.

Results

Ninety-two men with acetabular fractures without previously diagnosed urogenital injury responded to the survey at a minimum of 12 months and an average of 43 ± 21 months postinjury. The mean age was 53 ± 15 years. 39.8% of patients developed moderate-to-severe erectile dysfunction after injury. The mean EF domain score decreased 5.02 ± 1.73 points, which is greater than the minimum clinically important difference of 4. Increased injury severity score and associated fracture pattern were predictive of decreased EF score.

Conclusion

Patients with acetabular fractures have an increased rate of erectile dysfunction at intermediate-term follow-up. The orthopaedic trauma surgeon treating these injuries should be aware of this as a potential associated injury, ask their patients about their function, and make appropriate referrals.

Level of Evidence

III.

Delineating Which Patient-reported Symptoms Are Associated with Satisfaction After Urethroplasty

OBJECTIVE

To determine which patient-reported symptoms are associated with satisfaction after urethroplasty.

METHODS

From 2011 to 2018, patients were offered enrollment in a prospective study assessing patient-reported outcomes after urethroplasty. Outcomes were assessed preoperatively and 6-months postoperatively including patient satisfaction, voiding function (International Prostate Symptom Score), erectile function (International Index of Erectile Function 5) and ejaculatory function (ejaculatory component of brief sexual function inventory). Additionally, penile curvature/appearance, genitourinary pain, postvoid dribbling, and standing voiding function were also evaluated using either 3 or 5 point Likert scales. Stricture recurrence was defined as the inability to easily pass a 16Fr flexible videocystoscope. Multivariable binary logistic regression was used to examine the associations between outcomes and patient satisfaction.

RESULTS

A total of 387 patients completed the study with a mean age of 49.5 years and a mean stricture length of 4.5 cm. Location was bulbar (59.4%), penile (19.6%), posterior (13.7%) and pan-urethral (7.2%). At 6-months, 96.1% of patients were stricture-free, 81.6% reported being satisfied with surgery and 8% were unsatisfied. On multivariable binary logistic regression, improvement in International Prostate Symptom Score (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.1-1.2, P = .04), new erectile dysfunction (OR: 0.5, 95% CI: 0.2-0.9, P = .04), new penile curvature (OR: 0.4, 95% CI: 0.2-0.9, P = .03) and improved standing voiding function (OR: 1.3, 95% CI: 1.1-1.5, P = .004) were associated with patient satisfaction. Cystoscopic success (P = .60), change in pain score (P = .14), postvoid dribbling (P = .69), change in penile length (P = .44), and ejaculatory dysfunction (P = .51) were not.

CONCLUSION

Improved voiding function, patient-reported penile curvature, new erectile dysfunction and improved standing voiding are independently associated with patient satisfaction after urethroplasty and should be incorporated into any patient-centered approach to urethral stricture management.

Targets and study design for symptom-focused trials aimed at patients with cirrhosis: An expert consensus

BACKGROUND

Symptom-focused trials are critically needed for patients with cirrhosis. However, this work would benefit from standard processes and validated measures.

METHODS

A writing group was formed among hepatologists, nurses, palliative care providers, pharmacists, and clinical trial experts focused on symptom management in patients with cirrhosis to define the key (1) components of trial design, (2) symptom targets, (3) measurement, and (4) outcomes for each target. From July 2022 to January 2023, panelists participated in an iterative process of developing and arriving at a consensus for each component. The goal was to provide consensus definitions that can be operationalized in future clinical trials, including for patients with cirrhosis.

RESULTS

The panel reached a consensus on key reporting features for clinical trials, along with considerations for study design. Nine key symptom targets (muscle cramps, pruritus, pain, fatigue, sexual dysfunction, sleep disorders, depression and anxiety, nausea/vomiting, and dyspnea/breathlessness) were identified. The panel selected instruments that can be considered for clinical trials based on psychometric validation and previous experience. The panel identified ongoing needs, including instrument validation, safety data, evidence about non-pharmacologic interventions, and comparative effectiveness studies.

CONCLUSION

This expert panel identified key design, reporting, and measurement elements to standardize processes and measures in future symptom-focused clinical trials in the context of cirrhosis.

Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis

BACKGROUND

Total mesorectal excision (TME) for rectal cancer can be achieved using open (OpTME), laparoscopic (LapTME), robotic (RoTME), or transanal techniques (TaTME). However, the optimal approach for access remains controversial. The aim of this network meta-analysis was to assess operative and oncological outcomes of all four surgical techniques.

METHODS

Ovid MEDLINE, EMBASE, and PubMed databases were searched systematically from inception to September 2020, for randomised controlled trials (RCTs) comparing any two TME surgical techniques. A network meta-analysis using a Bayesian random-effects framework and mixed treatment comparison was performed. Primary outcomes were the rate of clear circumferential resection margin (CRM), defined as > 1 mm from the closest tumour to the cut edge of the tissue, and completeness of mesorectal excision. Secondary outcomes included radial and distal resection margin distance, postoperative complications, locoregional recurrence, disease-free survival, and overall survival. Surface under cumulative ranking (SUCRA) was used to rank the relative effectiveness of each intervention for each outcome. The higher the SUCRA value, the higher the likelihood that the intervention is in the top rank or one of the top ranks.

RESULTS

Thirty-two RCTs with a total of 6151 patients were included. Compared with OpTME, there was no difference in the rates of clear CRM: LapTME RR = 0.99 (95% (Credible interval) CrI 0.97-1.0); RoTME RR = 1.0 (95% CrI 0.96-1.1); TaTME RR = 1.0 (95% CrI 0.96-1.1). There was no difference in the rates of complete mesorectal excision: LapTME RR = 0.98 (95% CrI 0.98-1.1); RoTME RR = 1.1 (95% CrI 0.98-1.4); TaTME RR = 1.0 (95% CrI 0.91-1.2). RoTME was associated with improved distal resection margin distance compared to other techniques (SUCRA 99%). LapTME had a higher rate of conversion to open surgery when compared with RoTME: RoTME RR = 0.23 (95% CrI 0.034-0.70). Length of stay was shortest in RoTME compared to other surgical approaches: OpTME mean difference in days (MD) 3.3 (95% CrI 0.12-6.0); LapTME MD 1.7 (95% CrI - 1.1-4.4); TaTME MD 1.3 (95% CrI - 5.2-7.4). There were no differences in 5-year overall survival (LapTME HR 1.1, 95% CrI 0.74, 1.4; TaTME HR 1.7, 95% CrI 0.79, 3.4), disease-free survival rates (LapTME HR 1.1, 95% CrI 0.76, 1.4; TaTME HR 1.1, 95% CrI 0.52, 2.4), or anastomotic leakage (LapTME RR = 0.92 (95% CrI 0.63, 1.1); RoTME RR = 1.0 (95% CrI 0.48, 1.8); TaTME RR = 0.53 (95% CrI 0.19, 1.2). The overall quality of evidence as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments across all outcomes including primary and secondary outcomes was deemed low.

CONCLUSIONS

In selected patients eligible for a RCT, RoTME achieved improved distal resection margin distance and a shorter length of hospital stay. No other differences were observed in oncological or recovery parameters between (OpTME), laparoscopic (LapTME), robotic (RoTME), or trans-anal TME (TaTME). However, the overall quality of evidence across all outcomes was deemed low.

Impact of Ejaculation upon Effect of Acupuncture on Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Secondary Analysis of a Randomized Controlled Trial

Background

Acupuncture can improve chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Ejaculation frequencies might impact the conditions of CP/CPPS. The present study aimed to explore the impact of different ejaculation frequencies on the effect of acupuncture among men with CP/CPPS.

Methods

This was a secondary analysis of the data from a multicenter, randomized, clinical trial. Eligible participants were patients with moderate to severe CP/CPPS, who had taken 8-week acupuncture treatment, and followed until week 32. Participants fell into the category of 0-3, 4-7, or at least 8 according to their monthly ejaculation frequencies reported at baseline. The primary outcome was the proportion of responders, defined as men who reported at least 6 points reduction from baseline in the National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) total score at weeks 8 and 32.

Results

214 participants were included in this secondary analysis, of whom 42 reported a monthly ejaculation frequency of 0-3, 89 reported a frequency of 4-7, and 83 reported a frequency of at least 8. At week 8, 52.20% participants with an ejaculation frequency of 0-3 responded to the acupuncture treatment, 65.38% participants with a frequency of 4-7 responded, and 63.09% participants with a frequency of at least 8 responded. At week 32, 56.14%, 59.57%, and 68.36% participants responded in the three groups, respectively. No significant differences were observed between three groups (all P>0.05).

Conclusion

Acupuncture can improve symptoms of CP/CPPS, regardless of ejaculation frequencies. Ejaculation frequencies may not affect the efficacy of acupuncture on CP/CPPS among Chinese men.

Trial registration

ClinicalTrials.gov, NCT03213938.

Venous Leak Embolization in Patients with Venogenic Erectile Dysfunction via Deep Dorsal Penile Vein Access: Safety and Early Efficacy

PURPOSE

This all-comers registry aimed to assess safety and early efficacy of venous embolization in patients with venogenic erectile dysfunction due to venous leak in an unselected cohort.

METHODS

Between October 2019 and September 2022, patients with venogenic erectile dysfunction resistant to phosphodiesterase-5-inhibitors were treated with venous embolization using ultrasound-guided anterograde access via a deep dorsal penile vein in a single center. A mix of ethiodized oil and modified cyanoacrylate-based glue n-butyl 2 cyanoacrylate (NBCA) monomer plus methacryloxy-sulpholane monomer (Glubran-2, GEM, Italy) was used as liquid embolic agent. Prior to embolization, venous leak had been verified based on penile duplex sonography and computed tomography cavernosography. Procedural success was defined as technically successful and complete target vein embolization. The primary safety outcome measure was any major adverse event 6 weeks after the procedure. The primary feasibility outcome measure was IIEF-15 (International Index of Erectile Function-15) score improvement ≥ 4 points in ≥ 50% of subjects on 6 weeks follow-up post intervention.

RESULTS

Fifty consecutive patients (mean age 61.8 ± 10.0 years) with severe erectile dysfunction due to venous leak underwent venous embolization. Procedural success was achieved in 49/50 (98%) of patients with no major adverse events on follow-up. The primary feasibility outcome measure at 6 weeks was reached by 34/50 (68%) of patients.

CONCLUSION

Venous leak embolization via deep dorsal penile vein access using a liquid embolic agent was safe for all and efficacious in the majority of patients with severe venogenic erectile dysfunction on 6 weeks follow-up.

The impact of renal transplantation on sexual function in males with end-stage kidney disease: a systematic review and meta-analysis

INTRODUCTION

Patients with end-stage kidney disease (ESKD) on dialysis have a special profile, including constant uremic status and frequent comorbidities, such as diabetes mellitus, arterial hypertension and coronary artery disease, as well as complications related to dialysis. All listed factors can influence or be the cause of sexual dysfunction in both men and women. There is a high incidence (70%) and prevalence (82%) of erectile dysfunction in men with CKD.

PURPOSE

In this meta-analysis, we aimed to evaluate the impact of renal transplantation in patients with end-stage chronic kidney disease and erectile dysfunction, using the same study population before and after transplantation.

DATA SOURCES

we searched MEDLINE (PubMed), Embase, Scopus and Cochrane Library (Inception to August 2022) and clinicaltrials.gov (Inception to August 2022) without language restrictions.

STUDY SELECTION

eligible studies evaluated the same patients with end-stage kidney disease before and after renal transplantation using IEEF questionnaire.

DATA EXTRACTION

reviewers working independently and in duplicate extracted data and assessed the risk of bias.

DATA SYNTHESIS

the final analysis included 28 cohort studies, comprising 2252 participants.

RESULTS

Our results showed improvement in erectile function after renal transplantation. Our study shows a 13% improvement in erectile dysfunction after renal transplantation.

CONCLUSIONS

The results of this meta-analysis would suggest improvement in erectile dysfunction after renal transplantation.

Low-intensity shockwave treatment (LISWT) improves penile rigidity in eugonadal subjects with erectile dysfunction: a pilot study

BACKGROUND

Since low-intensity shockwave treatment (LISWT) has putative effects on penile hemodynamics remodeling, the aim of this study was to evaluate any improvement of penile vascular flows after LISWT treatment in patients with erectile dysfunction (ED) and poor response to PDE5i.

METHODS

Twenty-one eugonadal patients with different ED severity underwent 6 weekly LISWT sessions (1500-4000 pulses) after 2 weeks withdrawal from PDE5i assumption. Once daily Tadalafil (2.5 mg daily) was reintroduced 4 weeks apart from LISWT termination and patients were evaluated at 1, 2 and 6 months follow-up (T1, T2, T6) by the International Index of Erectile Function-15 items questionnaire (IIEF-15) erectile function (EF) domain, Erection Hardness Score (EHS) and Global Assessment Questionnaires (GAQ). Basal Penile Color-Doppler Ultrasound parameters in the flaccid state (B-PCDU) were evaluated before, during and after interventional protocol.

RESULTS

Mean EHS score improved in 35% of patients at T1, and in up to 50% of patients at T2 and T6 follow-up visits (P<0.05). We found 25% improvement of EF scores at T1 session, 43.75% at T2 and 62.5% at T6, respectively (P<0.05). No statistically significant differences in flow parameters, EF-domain and testosterone levels were found when baseline and last observation carried forward (LOCF) parameters were compared. The GAQ questionnaire scored higher satisfaction rates either at the end of the treatment (100%), or at LOCF (92.5%).

CONCLUSIONS

Despite the study limitations with respect to B-PCDU in this setting, our results confirm a trend toward improvement of erectile questionnaire scores after LISWT with higher overall satisfaction rates among patients with ED. We conclude that LISWT may be an effective option in some difficult-to-treat patients with ED by improving the erectile response to PDE5i.

Bipolar androgen therapy plus olaparib in men with metastatic castration-resistant prostate cancer

BACKGROUND

Bipolar androgen therapy (BAT) results in rapid fluctuation of testosterone (T) between near-castrate and supraphysiological levels and has shown promise in metastatic castration-resistant prostate cancer (mCRPC). Its clinical effects may be mediated through induction of DNA damage, and preclinical studies suggest synergy with PARP inhibitors.

PATIENTS AND METHODS

This was a single-center, Phase II trial testing olaparib plus BAT (T cypionate/enanthate 400 mg every 28 days) with ongoing androgen deprivation. Planned recruitment was 30 subjects (equal proportions with/without homologous recombination repair [HRR] gene mutations) with mCRPC post abiraterone and/or enzalutamide. The primary objective was to determine PSA50 response (PSA decline ≥50% from baseline) rate at 12-weeks. The primary analysis utilized the entire (intent-to-treat [ITT]) cohort, with those dropping out early counted as non-responders. Secondary/exploratory analyses were in those treated beyond 12-weeks (response-evaluable cohort).

RESULTS

Thirty-six patients enrolled and 6 discontinued prior to response assessment. In the ITT cohort, PSA50 response rate at 12-weeks was 11/36 (31%; 95% CI 17-48%), and 16/36 (44%, 95% CI 28-62%) had a PSA50 response at any time on-study. After a median follow-up of 19 months, the median clinical/radiographic progression-free survival in the ITT cohort was 13.0 months (95% CI 7-17). Clinical outcomes were similar regardless of HRR gene mutational status.

CONCLUSIONS

BAT plus olaparib is associated with high response rates and long PFS. Clinical benefit was observed regardless of HRR gene mutational status.

Feasibility of minimally invasive, same-day injection of autologous adipose-derived stem cells in the treatment of erectile dysfunction

OBJECTIVE

To investigate feasibility and safety of a new minimally invasive same-day method of autologous adipose derived stem cell (ADSC) transplantation in men suffering from ED.

MATERIALS AND METHODS

Prospective case series of 10 men with an IIEF-EF domain score <17. The IIEF questionnaire was filled out at baseline and 1, 2 and 3 months after treatment. Side effects were assessed by investigations and interviews until 6 months after treatment. The myStem® X2 kit was used for preparation of ADSC: Adipose tissue was harvested from the patient himself under local anesthesia and immediately prepared and injected into the penis. Primary endpoints were feasibility and safety. Secondary outcomes included effects on ED and changes in the remaining IIEF domains.

RESULTS

Ten men were included. Only one adverse event in the form of minor blue discoloration at the fat harvest site was registered. There were statistically significant improvements in IIEF-EF at one, two and three months after treatment compared to baseline with the median score increasing from 5.5 to 10.5, 10.5 and 10, respectively. Considering the individual patients, 3/10 men achieved an improvement equal to or greater than the minimal clinically important difference according to their baseline IIEF-EF score.

CONCLUSIONS

Our study confirms the feasibility and safety of this minimally invasive, same-day delivery of ADSC. Due to the design and size on the study, conclusions should not be drawn regarding efficacy, but the method seems worthy of further study.

Is Platelet Rich Plasma Safe and Effective in Treatment of Erectile Dysfunction? Randomized Controlled Study

OBJECTIVE

To evaluate the safety and efficacy of platelet rich plasma (PRP) injections as a therapeutic modality for mild to moderate erectile dysfunction.

METHODS

A placebo-controlled study of 100 cases with mild to moderate erectile dysfunction. Participants were allocated to 2 groups; the PRP group received 3 injections (3 mL each corpus) and the interval between injections was 15 days, while the Placebo (Saline) group received 6 mL saline injected intracavernous. Postinjection follow-up lasted 6 months.

RESULTS

Compared to the placebo group, the PRP group demonstrated a significant improvement at the 1 and 3 months follow-up that slightly dropped at the 6 months follow-up (P <.001). The improvement was evident in the duplex parameters, International Index of Erectile Function Erectile Function (IIEF-EF), SEP Q2, and 3. At 1-month post-treatment follow-up (76%) patients in the PRP group had an improved IIEF-EF as they attained a minimal clinically important difference compared to (18%) in the saline group. At the 3-months post-treatment follow-up, (72%) patients achieved a minimal clinically important difference in the PRP group vs (16%) in saline group then dropped to (70%) in the PRP group vs (16%) in saline group at the 6-months post-treatment follow up. Patients' overall and intercourse satisfaction levels were higher in the PRP group than the placebo group as demonstrated with the higher IIEF score Q6, 7, 8, and IIEF score Q13, 14 respectively with the maximum improvement reported at the 3 months follow-up. No reports of plaque formation, subcutaneous bruising, or any other major side effects among participants.

CONCLUSION

PRP is a safe and promising method for the improvement of mild to moderate erectile dysfunction.

Rehabilitation of People With Chronic Spinal Cord Injury Using a Laparoscopically Implanted Neurostimulator: Impact on Mobility and Urinary, Anorectal, and Sexual Functions

OBJECTIVES

This study aimed to assess the impact of the laparoscopic implantation of neuromodulation electrodes (Possover-LION procedure) on mobility and on sexual, urinary, and anorectal functions of people with chronic spinal cord injury (SCI).

MATERIAL AND METHODS

Longitudinal analysis of 30 patients with chronic SCI (21 ASIA impairment scale (AIS) A, eight AIS B, and one AIS C) submitted to the Possover-LION procedure for bilateral neuromodulation of femoral, sciatic, and pudendal nerves. Assessments were performed before the surgical procedure and at 3, 6, and 12 months postoperatively. The primary outcome was evolution in walking, measured by the Walking Index for Spinal Cord Injury score, preoperatively and at 12 months. Secondary outcomes were changes in overall mobility (Mobility Assessment Tool for Evaluation of Rehabilitation score), urinary function and quality of life (Qualiveen questionnaire), and bowel (time for bowel emptying proceedings and Wexner's Fecal Incontinence Severity Index [FISI]) and sexual functions (International Index of Erectile Function for men and Female Sexual Function Index for women). Surgical time, intraoperative bleeding, and perioperative complications were also recorded.

RESULTS

Qualitatively, 18 of 25 (72%) patients with thoracic injury and 3 of 5 (60%) patients with cervical injury managed to establish a walker-assisted gait at one-year follow-up (p < 0.0001). A total of 11 (47.8%) have improved in their urinary incontinence (p < 0.0001), and seven (30.4%) improved their enuresis (p = 0.0156). The FISI improved from a median of 9 points preoperatively to 5.5 at 12 months (p = 0.0056). Of note, 20 of 28 (71.4%) patients reported an improvement on genital sensitivity at 12 months postoperatively (p < 0.0001), but this was not reflected in sexual quality-of-life questionnaires.

CONCLUSIONS

Patients experienced improved mobility and genital sensitivity and a reduction in the number of urinary and fecal incontinence episodes. By demonstrating reproducible outcomes and safety, this study helps establish the Possover-LION procedure as an addition to the therapeutic armamentarium for the rehabilitation of patients with chronic SCI.

CLINICAL TRIAL REGISTRATION

This study was registered at the WHO Clinical Trials Database through the Brazilian Registry of Clinical Trials-REBEC (Universal Tracking Number: U1111-1261-4428).

A Prospective, Randomized, Double-Blinded, Clinical Trial Using a Second-Generation Duolith SD1 Low-Intensity Shockwave Machine in Males with Vascular Erectile Dysfunction

PURPOSE

To evaluate the clinical efficacy and patient satisfaction rates of low-intensity extracorporeal shockwave therapy LIESWT) in men with vasculogenic erectile dysfunction (ED) using Duolith SD1 machine.

MATERIALS AND METHODS

This prospective, randomized, double-blinded clinical trial included 60 men who were randomly assigned to LIESWT (n=30, active group) or placebo (n=30) over 6 weeks. Patient demographics, change in International Index of Erectile Function (IIEF)-5, Erection Hardness Score (EHS) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, and an overall satisfaction score (on a 5-point scale), were recorded. All patients were reviewed at 1, 3, and 6 months after completion of therapy.

RESULTS

There were 21 (70%) patients in the LIESWT group and 3 (10%) patients in the placebo group who had a 5-point or greater increase in IIEF-5 score (p=0.018). At 6-month study period, the mean IIEF-5 score was 18.8 (standard deviation [SD], 3.8) in the LIESWT group versus 14.8 (SD, 3.6) in the placebo group, difference in means between groups was 4.0 (95% confidence interval, 2.1-5.9; p<0.001). The EHS scores were higher in the LIESWT group with a mean of greater than 1.2 across the 1, 3, and 6 months compared to the placebo group (p<0.05). All patients completed the treatment study and there was no adverse event reported in terms of penile pain, bruising or deformity. There was a positive correlation between men who reported improvement in EF and treatment satisfaction level with LiESWT (p=0.008).

CONCLUSIONS

LIESWT improves erectile function in the short-term especially in men with mild to moderate ED, and those without a cardiometabolic disease.

Rationale and Design for the COCKTAIL Trial: A Single-center, Randomized, Double-blind, Sham-controlled Study Combining Shockwave Therapy and Platelet-rich Plasma for Erectile Dysfunction

Restorative therapies are a promising option for the treatment of erectile dysfunction. Several studies have assessed platelet-rich plasma and shockwave therapy alone. However, COCKTAIL is the first study to evaluate the synergistic effects of these two therapies in combination.

The role of testosterone in male sexual function

Sexual function, and testosterone (T) levels, progressively decline in aging men. Associated morbidities and metabolic disorders can accelerate the phenomenon. The specific contribution of low T to sexual function impairment in aging men has still not been completely clarified. Similarly, the role of T replacement therapy (TRT), as well as the combination of TRT with phosphodiesterase type 5 inhibitors (PDE5i) for patients with erectile dysfunction (ED), is still conflicting. Here we aim to summarize and critically discuss all available data supporting the contribution of low T to sexual impairment observed with aging as well as the possible role of TRT. Available data on men with sexual dysfunction show that reduced sexual desire is the most important correlate of male hypogonadism. Conversely, aging and associated morbidities substantially attenuate the relationship between ED and T. TRT is effective in improving sexual function in middle-aged and older subjects but its role is small and extremely variable. Lifestyle interventions can result in similar outcomes to those of TRT. In conclusion, it is our opinion that PDE5i along with lifestyle measures should be considered the first approach for treating ED even in subjects with milder T deficiency. When these interventions fail or are difficult to apply, TRT should be considered.

An Evaluation of Sexual Function in the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia in Men Treated with the Temporarily Implanted Nitinol Device

Purpose: To document the effect of the temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Israel) on sexual function from a multicenter, randomized, single-blinded, sham-controlled trial. Materials and Methods: Men were randomized 2:1 between iTind and sham procedure arms. The iTind was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 3, and 12 months postoperatively using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF). Unblinding occurred at 3 months. Results: We studied 185 men with a mean age of 61.1 ± 6.5 years. There was no difference in SHIM or total IIEF between iTind and sham at 3 months or in the iTind arm at 12 months compared with baseline. Men in the iTind arm without erectile dysfunction at baseline showed an improvement in total IIEF score of +6.07 ± 21.17 points (p = 0.034) at 12 months, in addition to an improvement in ejaculatory function. SHIM scores remained unchanged in all groups, regardless of age, prostate volume, or baseline erectile function. Conclusion: No changes were observed in sexual and ejaculatory function of patients with iTind regardless of a man's age, prostate volume, and baseline sexual function. Clinicaltrials.gov: NCT02506465.

Erectile and Ejaculatory Function Following Anterior Urethroplasty: A Systematic Review and Meta-analysis

CONTEXT

The degree of change in erectile (EF) and ejaculatory function (EjF) according to validated questionnaires following anterior urethroplasty and different techniques is unclear.

OBJECTIVE

To investigate the evidence on EF and EjF evaluated via validated questionnaires following anterior urethroplasty.

EVIDENCE ACQUISITION

A systematic review (PROSPERO ID: CRD42021229797) of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The PubMed and CENTRAL databases were searched on February 1, 2021, with an updated search performed on December 1, 2021. Studies evaluating EF and/or EjF using validated questionnaires in men aged ≥18 yr following anterior urethroplasty were included.

EVIDENCE SYNTHESIS

Overall, 29 studies (two randomised and 27 nonrandomised) were included. The questionnaire most commonly used to evaluate EF and EjF was the International Index of Erectile Function (IIEF) and Male Sexual Health Questionnaire (MSHQ), respectively. The incidence of postoperative erectile dysfunction (ED) was 0-38% and the mean change in EF score according to the IIEF ranged from -4.0 to 2.5. The incidence of postoperative ejaculatory dysfunction (EjD) was 7.7-67% and the mean change in EjF score according to the MSHQ-EjD was 0.7-7.0. Meta-analyses revealed a mean difference of -0.87 (95% confidence interval [CI] -1.50 to -0.23; p = 0.008) in IIEF-EF score and 1.77 (95% CI 0.61-2.93; p = 0.003) in MSHQ-EjF score following anterior urethroplasty.

CONCLUSIONS

EF and EjF may be affected following anterior urethroplasty and men should be counselled appropriately. Owing to the variation in questionnaires and cutoff scores used, EF and EjF outcomes following different urethroplasty techniques are heterogeneous, with limited data from randomised controlled trials. An agreement on questionnaires and cutoff scores should be established to allow consistent reporting. Future research should aim to investigate best approaches for minimising sexual dysfunction.

PATIENT SUMMARY

Surgical repair of the urethra (urethroplasty) used to treat narrowing of the urethra (urethral stricture) may affect erectile and ejaculatory function. Different questionnaires and definitions are used to evaluate sexual function, so it is hard to compare data. The degree of disruption can be affected by different techniques and the severity of disease.

The earthquake's effect on the men's sexual function; 1 year after the earthquake's occurrence: A cross-sectional study

Background and Aims

Sexual dysfunctions are one of the health problems after natural disasters that are usually less attention. The purpose of this study was to evaluate the effect of the earthquake on men's sexual functions 1 year after the earthquake.

Methods

This study was a descriptive-analytical cross-section study that took place a year after the Kermanshah earthquake. The population studied was all men living in the Kermanshah earthquake. Demographic, socioeconomic, psychological, health situations, facilities availability, and environmental situations after the earthquake and International Index of Erectile Function (IIEF) were randomly distributed among men affected by the earthquake. Participants returned the questionnaires through the mail. Based on the IIEF cut-point score, men were divided into two groups: those with sexual dysfunction (Group A) and without sexual dysfunction (Group B).

Results

In this study, 225 married men participated. The prevalence of sexual dysfunction in earthquake-affected men was 44.9%. The mean total IIEF scores in the A and B groups were 43.47 ± 7.82 and 62.11 ± 6.39, respectively. There was a significant difference between the total and all subcategories IIEF scores in the two groups (p < 0.001). There was a statistically significant difference between the age (p < 0.001), child numbers (p < 0.017), current live location (p < 0.001), social support after the earthquake (p = 0.033), underlying disease (p < 0.001), availability of sanitary toilets (p < 0.001) and bathrooms (p = 0.002), and total IIEF scores between the two groups (p < 0.001).

Conclusions

Approximately half of the earthquake-affected men had sexual dysfunctions. The men's age, child numbers, current live location, social support, underlying disease, and availability of sanitary toilets and bathrooms were influential in the severity of men's sexual dysfunctions after the earthquake. Therefore, crisis managers, policymakers, psychiatrists, and psychologists should pay enough attention to men's sexual dysfunction after earthquakes.

Focal Therapy for Prostate Cancer: The Impact on Sexual Function

Focal therapy (FT) has emerged as a potential treatment for localized prostate cancer (PCa) with encouraging functional outcomes. According to the compelling evidence based on meta-analyses and recent trials, erectile function (EF) is mostly retained at 6 and 12 months after FT when compared to baseline. These findings are consistent across different energy sources reported to date. However, overall, quality of life, including impotence, was not the endpoint for most studies. Additionally, impotency has not been consistently reported in most of the recent literature. Furthermore, confounding factors such as baseline potency and usage of phosphodiesterase 5 inhibitors (PDE5-I) were also frequently undisclosed. Long-term functional outcomes are awaited. To fully comprehend how FT affects EF, more extensive long-term randomized clinical trials using EF as a primary outcome are needed.

The Efficacy and Safety of Thrice vs Twice per Week Low-Intensity Pulsed Ultrasound Therapy for Erectile Dysfunction: A Randomized Clinical Trial

BACKGROUND

A recent sham-controlled clinical study has shown that low-intensity pulsed ultrasound twice per week can safely and effectively treat patients with mild-to-moderate erectile dysfunction (ED). However, large-scale clinical trials are needed to verify its efficacy and safety and determine a reasonable treatment interval.

AIM

To study whether low-intensity pulsed ultrasound therapy thrice per week is non-inferior to twice per week in patients with mild-to-moderate ED.

METHODS

A randomized, open-label, parallel-group, non-inferiority clinical trial was conducted in 7 hospitals in China. A total of 323 patients with mild-to-moderate ED were randomized (1:1) into thrice per week (3/W) and twice per week (2/W) groups. Low-intensity pulsed ultrasound was applied on each side of the penis for 16 sessions.

OUTCOMES

The primary outcome was response rate using the minimal clinically important difference in the International Index of Erectile Function (IIEF-EF) score at week 12. Secondary outcomes included Erection Hardness Score (EHS), Sexual Encounter Profile, Global Assessment Question, and Self Esteem and Relationship Questionnaire.

RESULTS

Response rates in 3/W and 2/W groups were 62.0% and 62.5%, respectively. Treatment effect in the 3/W group was noninferior to that of the 2/W group, with rate difference lower bound of -0.01% [95% confidence interval -0.11 to 0.10%] within the acceptable margin (-14.0%). No significant difference was found among secondary outcomes. IIEF-EF score showed a significant increase from baseline in the 3/W group (16.8 to 20.7) and 2/W group (17.8 to 21.7), and the percentage of patients with EHS ≥3 increased in the 3/W (54.9% to 84.0%) and 2/W (59.5% to 83.5%) groups. There was no significant difference in response rate between the 2 groups after controlling for strata factors and homogeneous tests. No treatment-related adverse events were reported.

CLINICAL IMPLICATIONS

Low-intensity pulsed ultrasound therapy displays similar efficacy and safety for mild-to-moderate ED when administered thrice or twice per week for 16 sessions. This study provides two options to suit patients' needs.

STRENGTHS & LIMITATIONS

This is a large-sample, randomized, controlled, noninferiority trial study. Short-term follow-up and mostly younger patients are the main limitations.

CONCLUSION

Low-intensity pulsed ultrasound therapy thrice and twice per week showed equivalent therapeutic effects and safety for mild-to-moderate ED in a young and generally healthy population. This therapy warrants further investigation of its potential value in rehabilitation of ED.

Randomized, Open-Label Phase 2 Study of Apalutamide plus Androgen Deprivation Therapy versus Apalutamide Monotherapy versus Androgen Deprivation Monotherapy in Patients with Biochemically Recurrent Prostate Cancer

Purpose. This randomized phase 2 study sought to assess the treatment effect of a finite duration of apalutamide with and without androgen deprivation therapy (ADT) in biochemically recurrent prostate cancer (BCR PC). Materials and Methods. Patients with BCR PC after primary definitive therapy and prostate-specific antigen (PSA) doubling time ≤12 months were randomized to open-label apalutamide (240 mg/d) alone, apalutamide plus ADT, or ADT alone (1 : 1:1 ratio) for 12 months followed by a 12-month observation period (NCT01790126). Mean changes from baseline in Functional Assessment of Cancer Therapy-Prostate (FACT-P) at 12 months (primary endpoint) and other prespecified assessments of health-related quality of life (HRQoL), PSA nadir, time to PSA progression, time to testosterone recovery, recovered testosterone >150 ng/dL without PSA progression at 24 months, and molecular markers were evaluated. Results. In 90 enrolled patients (apalutamide plus ADT (n = 31), apalutamide (n = 29), ADT (n = 30)), FACT-P at 12 months was not significantly different between apalutamide, ADT and apalutamide, and ADT groups. Addition of apalutamide to ADT prolonged time to PSA progression but this change did not reach statistical significance (hazard ratio (HR): 0.56, 95% confidence interval (CI): 0.23–1.36, $P=0.196$ ); time to testosterone recovery was similar in the ADT-containing groups. In apalutamide plus ADT, apalutamide, and ADT groups, 37.9%, 37.0%, and 19.2% of patients, respectively, had testosterone >150 ng/dL at 24 months without confirmed PSA progression. Of the few biomarkers expressed in blood, EPHA3 was significantly associated with shorter time to PSA progression ( $P=0.02$ ) in the overall population. Conclusions. HRQoL was similar in patients treated with apalutamide alone, ADT alone, or their combination, although apalutamide plus ADT did not demonstrate statistically significant noninferiority in change from baseline in overall HRQoL. The aggregated efficacy and safety outcomes support further evaluation of apalutamide plus ADT in BCR PC.

Early outcomes of short-course low intensity shockwave therapy (LiSWT) for erectile dysfunction: A prospective, randomized, double-blinded, sham-controlled study in Malaysia

Low‐intensity shockwave therapy (LiSWT) has emerged as a promising non‐invasive treatment modality for erectile dysfunction (ED) yet the well‐designed randomized clinical trials are still lacking to prove its claimed benefits. A randomized, prospective, double‐blinded sham‐controlled study was conducted to evaluate the effectiveness and safety profile of short course LiSWT on vasculogenic ED patients. The International Index of Erectile Function‐5 (IIEF‐5) and Erection Hardness Score (EHS) questionnaires were used for evaluation. Patients underwent weekly sessions for 4 weeks and were re‐assessed at 1, 3 and 6 months post therapy. Fifty one patients were recruited and randomized into sham and treatment arms. The mean IIEF‐5 scores were significantly improved in the treatment arm compared to worsening of scores in the sham arm after 1 month (14.1 vs. 9.3 p < 0.001), 3 months (14.9 vs. 8.6, p < 0.001) and 6 months (14.2 vs. 7.9, p < 0.001) post treatment. A significant improvement of EHS was demonstrated at 1 month (2.4 vs. 1.8, p = 0.001, 3 months 2.7 vs. 1.7, p < 0.001) and 6 months (2.7 vs. 1.6, p < 0.001) in the treatment arm compared to sham arm. The success rate based on IIEF score increment more than five points was 26% in treatment arm and 0% in sham arm. Improvement in EHS score ≥3 in the treatment versus sham arm was 63% and 4%, respectively. There was no adverse effect reported. This 4‐week LiSWT protocol reflects better treatment compliance, and it prevents further deterioration of erectile function among this cohort of patients. This study proves that LiSWT is a well‐tolerated treatment with modest improvements in erectile function and hardness, among patients with vasculogenic ED.

Ageing male (part 2): Management of functional hypogonadism in older men, a patient-centric holistic approach

The diagnosis of functional hypogonadism should prompt a thorough assessment and optimization of general health, including lifestyle changes, weight reduction, care of comorbidities and cessation of offending medications, some of which can lead to meaningful gains in endogenous testosterone (T) concentrations. Having excluded or addressed reversible causes and contra-indications, patients with functional hypogonadism can be offered a trial of testosterone replacement therapy (TRT) after full discussion on the anticipated benefits and potential risks. T treatment improves libido but may be less effective for erectile dysfunction (ED). T treatment can also have modest positive effects on insulin resistance, bone strength, some measures of physical strength, and mild depressive symptoms but the clinical significance of these relatively short-term improvements remain uncertain in terms of longer-term patient-important outcomes. Initiation of TRT is a joint decision between patient and clinician since longer-term benefits and risks have not been adequately defined.

Transpelvic Magnetic Stimulation Enhances Penile Microvascular Perfusion in a Rat Model: A Novel Interventional Strategy to Prevent Penile Fibrosis after Cavernosal Nerve Injury

PURPOSE

Penile microvascular dysfunction is a known contributor to erectile dysfunction (ED) and penile fibrosis has been shown to impair microvascular perfusion (MVP). Our objectives were to: (i) determine beneficial effects of TPMS to modulate penile MVP, (ii) determine its mechanism, (iii) evaluate impact of cavernosal nerve injury (CNI) on penile MVP, and (iv) determine time-course of cavernosal tissue elastin changes after CNI in rats.

MATERIALS AND METHODS

Adult male rats (n=5) were anesthetized and subjected to TPMS (13%, 15%, and 17%) and MVP changes were recorded using laser speckle contrast imaging (LSCI). Another group of male rats were subjected to either bilateral cavernosal nerve injury (CNI; n=7) or sham surgery (n=7). After recovery, animals were monitored for MVP using LSCI before and after TPMS. Rat penile tissues were harvested and analyzed for fibrosis using a marker for elastin.

RESULTS

Rat TPMS resulted in a stimulus dependent increase in MVP; maximal perfusion was observed at 17%. L-N(G)-Nitroarginine methyl ester (L-NAME) resulted in a marked decrease in TPMS induced MVP increase (393.33 AU vs. 210.67 AU). CNI resulted in 40% to 50% decrease in MVP. CNI produced a remarkable increase in elastin deposits that are noticeable throughout the cavernosal tissues post injury.

CONCLUSIONS

TPMS is a novel and non-invasive intervention to improve penile MVP after CNI. Potential application includes treatment of ED and sexual function preservation following cancer treatment, possibly through improved penile hemodynamics that might help prevent penile hypoxia and fibrosis.

mpMRI-US Fusion-Guided Targeted Cryotherapy in Patients with Primary Localized Prostate Cancer: A Prospective Analysis of Oncological and Functional Outcomes

Simple Summary

Targeted cryotherapy is an emerging treatment for prostate cancer (PCa). mpMRI is a powerful tool for image fusion techniques that deliver incremental precision in diagnostic and treatment of PCa. Fusion targeted cryotherapy (FTC) arises from the simultaneous application of both these procedures. Recurrence is a concern after any type of PCa treatment, especially after targeted treatments. In this article we investigate the recurrence rate after FTC and the role of Prostate-Specific Antigen (PSA) as a predictor of recurrences. Our research provides new evidence on the feasibility of FCT by providing new insights on patient management.

Abstract

Targeted therapy (TT) for prostate cancer (PCa) aims to ablate the malignant lesion with an adequate margin of safety in order to obtain similar oncological outcomes, but with less toxicity than radical treatments. The main aim of this study was to evaluate the recurrence rate (RR) in patients with primary localized PCa undergoing mpMRI/US fusion targeted cryotherapy (FTC). A secondary objective was to evaluate prostate-specific antigen (PSA) as a predictor of recurrences. We designed a prospective single-center single-cohort study. Patients with primary localized PCa, mono or multifocal lesions, PSA ≤ 15 ng/mL, and a Gleason score (GS) ≤ 4 + 3 undergoing FTC were enrolled. RR was chosen as the primary outcome. Recurrence was defined as the presence of clinically significant prostate cancer in the treated areas. PSA values measured at different times were tested as predictors of recurrence. Continuous variables were assessed with the Bayesian t-test and categorical assessments with the chix-squared test. Univariate and logistic regression assessment were used for predictions. A total of 75 cases were included in the study. Ten subjects developed a recurrence (RR: 15.2%), while fifty-six (84.8%) patients showed a recurrence-free status. A %PSA drop of 31.5% during the first 12 months after treatment predicted a recurrence with a sensitivity of 53.8% and a specificity of 79.2%. A PSA drop of 55.3% 12 months after treatment predicted a recurrence with a sensitivity of 91.7% and a specificity of 51.9%. FTC for primary localized PCa seems to be associated with a low but not negligible percentage of recurrences. Serum PSA levels may have a role indicating RR.

Pilot study of intra-cavernous injections of platelet-rich plasma (P-shot®) in the treatment of vascular erectile dysfunction

INTRODUCTION

Intracavernosal injections of platelet-rich plasma (PRP) or P-shot® are increasingly proposed as a curative treatment for organic sexual dysfunction despite the lack of evidence of effectiveness.

OBJECTIVES

We conducted a pilot study to evaluate the safety and efficacy of intracavernous PRP injections in patients with vascular erectile dysfunction (ED).

METHODS

Three intracavernosal injections of PRP were performed 15days apart in 15 patients with vascular ED unresponsive to medical treatment with 5-phosphodiesterase inhibitors and/or prostaglandin E instillations or injections. Questionnaires assessing erectile function (IIEF-EF, EHS, SEP, Sexual discomfort score) were completed prior to treatment and 1, 3 and 6 months after the last injection.

RESULTS

No side effects were noted during the study period. The IIEF-EF score was significantly improved after treatment (P<0.001) with a gain of 5 points at 1month, 4 points at 3months and 3 points at 6months (respectively P=0.001, P=0.003 and P=0.022). The other questionnaires did not change significantly. In total, 20% of patients considered that the erection lasted long enough to have a sexual intercourse (SEP score) before P-shot® versus 26.7% after the treatment (P=1).

CONCLUSION

This study suggests that the effect of P-Shot® remains moderate in cases of ED with vascular origin. Larger clinical studies are needed to determine the real effectiveness of this therapeutic strategy.

LEVEL OF PROOF

2.

Assessment of a New Formulation of Sildenafil on Common Practice: An Observational Study

Erectile dysfunction (ED) has a significant impact on the quality of life of patients. Xybilun® (IBSA Pharma SAS, France) is a new formulation of sildenafil in an orodispersible film (ODF). This study aims to assess the response rate (RR), satisfaction with, and safety of sildenafil-ODF in daily practice in France. Patients aged ≥18 years with ED were included in four groups: Group 1 mild, Group 2 moderate, Group 3 severe ED, according to the International Index for Erectile Function (IIEF)-6 subscore, never treated with phosphodiesterase inhibitors (PDE)5-I; Group 4, patients previously treated with another PDE5-I. Patients were evaluated at baseline (V1), one (V2), and three (V3) months. The RR and satisfaction were assessed using the IIEF-6 subscore questionnaire, a 5-point Likert scale, and a Global Assessment Question (GAQ). The primary endpoint for Groups 1 to 3 was the RR according to Rosen criteria at V3 compared to V1. For Group 4, the primary endpoint was the RR, defined as the satisfaction compared with previous treatment. Secondary endpoints were the RR at V2 compared to V1, the evolution of IIEF-6 and IIEF-15 scores, dose adjustment, satisfaction, convenience, and safety. One hundred and five patients were enrolled, 83 analysed. The RR at V3 was 100% (Group 1); 75% (Group 2); 65.2% (Group 3); and 84.2% (Group 4). The overall RR was 78.3%. Secondary parameters confirmed the satisfaction with sildenafil-ODF, with 81.6% of patients very satisfied at V3. No Serious Adverse Events (SAEs) were observed. In conclusion, sildenafil-ODF seems beneficial for patients irrespective of the severity of the ED. This study confirms in the context of daily clinical practice the satisfaction of patients with sildenafil-ODF. Data suggest that the availability of the intermediate dose of 75 mg could add greater flexibility to the therapy.

The AdVance Sling and Male Sexual Function: A Prospective Analysis on the Impact of Pelvic Mesh on Erectile and Orgasmic Domains in Sexually Active Men With Postprostatectomy Stress Urinary Incontinence

Background

Transvaginal pelvic mesh surgery has been shown to cause female sexual dysfunction.

Aim

To evaluate the sexual function impact of AdVance male sling (MS) on erectile and orgasmic domains.

Methods

A review of a prospectively collected database was conducted in all sexually active men who underwent AdVance MS for postprostatectomy stress urinary incontinence between 2012 and 2018.

Outcomes

Patient demographics, clinical outcomes, and validated questionnaires such as the Brief Male Sexual Function Inventory (BMSFI), International Index of Erectile Function (IIEF) and Patient Global Impression of Improvement (PGI-I) were reviewed at 6, 12 and 24 months.

Results

Of the total of 65 men who received AdVance sling, an increase in IIEF-5 score ≥5 points were reported in 10 (15%) patients with no patients complained of deteriorating erectile function at 24 months. The improvement in orgasmic function (Question 10 on IIEF-15) was reported in 22 (34%) patients while 3 (5%) patients reported lower orgasmic scores. The sexual domains scores in BMSFI were higher in 40 (62%) patients, especially with regards to sexual desire (Question 1 and 2) and satisfaction with sex life (Question 11). No patient reports pelvic or urethral pain. The reported improvement in erectile and orgasm scores remained similar throughout the 24-months follow-up period. All 20 patients with preoperative climacturia reported resolution of their symptoms during sexual activity. The overall PGI-I was 1.4 (1–3) and men with a higher continence rate were more likely to report better male sexual function (P = .044).

Clinical implications

AdVance MS appears to improve erectile and orgasmic domains, and there is a positive correlation between urinary continence and male sexual function.

Strengths and limitations

Strengths of this study include the prospective large patient population analyzed regarding the impact of MS on male sexual function with the use of validated instruments for erectile, orgasmic, and urinary domains. Limitations include single-centre data, relatively short-term follow-up study and lack of a comparative arm.

Conclusion

Despite the reported adverse effect of sexual dysfunction following pelvic mesh in the female population, the AdVance PMS appears to improve male sexual function with regards to erectile and orgasm domains.

Chung E, Wang J. The AdVance Sling and Male Sexual Function: A Prospective Analysis on the Impact of Pelvic Mesh on Erectile and Orgasmic Domains in Sexually Active Men With Postprostatectomy Stress Urinary Incontinence. Sex Med 2022;10:100529.

The effect of vitamin D replacement in patients with lower urinary tract complaint/erectile dysfunction resistant to Tadalafil 5 mg treatment: A pilot clinical study

The aim of this study was to evaluate the effect of vitamin D replacement in patients with lower urinary tract symptoms (LUTS)/erectile dysfunction (ED) who did not respond to tadalafil 5 mg treatment. Patients who applied to the Andrology Clinic with LUTS/ED between September 2017 and August 2020 and used 5 mg Tadalafil daily for treatment and did not benefit from treatment for 1 month were included in the study. Vitamin D levels of the patients were analysed and Vitamin D3 100,000 IU/week oral therapy was administered for a month to the patients with low levels of Vitamin D(<20 ng/ml).The values of the patients before and after Vitamin D replacement were compared. A total of 84 patients were included in the study. The mean age was 49.175 ± 11.63(28-70) years and the mean BMI was 25.93 ± 6.82(18.26-37.87). Testosterone levels of the examined patients were 3.45 ± 0.99 ng/ml. After 1 month of Vitamin D replacement + Tadalafil 5 mg/d treatment, the international index of erectile function-erectile function (IIEF-EF) (pre-treatment: 10.73 ± 6.12, post-treatment: 24.18 ± 4.87; p = 0.001) and International Prostate Symptom Score (pre-treatment: 9.12 ± 7.16, post-treatment: 3.11 ± 1.08; p = 0.003) scores of the patients improved significantly. Evaluation of Vitamin D levels is important to improve treatment response, especially in patients who do not respond to PDE-5 inhibitors.

Are Radial Pressure Waves Effective for the Treatment of Moderate or Mild to Moderate Erectile Dysfunction? A Randomized Sham Therapy Controlled Clinical Trial

INTRODUCTION

Radial wave therapy is commercialized as an option for the management of erectile dysfunction. However, the mechanism of action of the radial waves differs substantially from shock waves, so the evidence gathered for shock wave therapy cannot be extrapolated, and there are very few clinical trials with the radial wave.

AIM

To assess the efficacy and safety of radial wave therapy compared with sham therapy for the treatment of moderate and mild to moderate erectile dysfunction.

METHODS

A randomized, double-blind, sham-controlled clinical trial was realized. Eighty patients with moderate erectile dysfunction, without sickle cell anemia, anticoagulation treatment, comorbidities, or conditions associated with secondary erectile dysfunction were included. The efficacy and safety were assessed at 6 and 10 weeks after randomization. Patients were randomized 1:1 to 1 of 2 arms: (i) 6 weekly sessions of radial wave therapy (RW group) or (ii) 6 weekly sessions of sham therapy (control group). All patients received sildenafil 25 mg.

OUTCOME

The primary outcome was the mean change in the International Index of Erectile Function - Erectile Function (IIEF-EF) domain score at 6 weeks after randomization.

RESULTS

Eighty men were randomized. The average baseline IIEF-EF score was 16.3 (Standard Deviation - SD 3.2), and the median baseline Erection Hardness Score (EHS) was 3 (IQR 1). At 6 weeks after randomization, the mean change in the IIEF-EF score was 3.4 (95% confidence interval [CI] 1.5-5.2) in the RW group and 4.2 (95% CI 2.5-5.9) in the control group. No differences were observed between groups (P value =.742). No change was observed in the median EHS score in the evaluations. No serious adverse events occurred in 2 (5%) patients after radial wave therapy, and in 1 (2.5%) patient after sham therapy.

CLINICAL IMPLICATIONS

Knowledge of the effectiveness of radial waves protocols used for the treatment of moderate erectile dysfunction, helps doctors and patients in making decisions about the use of this therapy.

STRENGTHS & LIMITATIONS

One strength is conducting the study with high methodological standards to minimize risk biases. Our results are limited to the evaluation of 1 specific protocol in moderate and mild to moderate erectile dysfunction.

CONCLUSIONS

No difference was found in this study between men with moderate and mild to moderate erectile dysfunction treated with radial waves and men treated with placebo sham therapy. Studies with different protocols of radial waves are necessary. Sandoval-Salinas C, Saffon JP, Martínez JM, et al. Are Radial Pressure Waves Effective for the Treatment of Moderate or Mild to Moderate Erectile Dysfunction? A Randomized Sham Therapy Controlled Clinical Trial. J Sex Med 2022;19:738-744.

Establishment of a nurse-led clinic for late complications after colorectal and anal cancer surgery: a descriptive study

Purpose

Survival rates after colorectal and anal cancer are increasing and more patients have late complications to treatment. This represents a clinical field under development, and we have established a specialized clinic for late complications after colorectal and anal cancer. With this paper, we want to give our experiences and present the organizational setup with a nurse as the primary contact person.

Methods

We have established a multidisciplinary clinic for the treatment of late complications and the clinic is organized with specialized nurses as the front persons. The structure includes a stepwise increase in expertise level when needed, and the patient has one common entry regardless of symptoms. Initial screening is performed by an electronic questionnaire which is followed up by a consultation with the nurse. The nurse can provide primary treatment according to local algorithms developed in the clinic and refer the patient to more specialized care if needed.

Results

Experiences from the first year of service show that more than half of the patients needs this and wants consultation in the late complication clinic. We also found that most of the consultations were performed successfully by phone instead of by physical visits, and the most common clinical problem was bowel symptoms including diarrhea and urge.

Conclusion

We have established a nurse-led clinic for late complications after colorectal and anal cancer. There seems to be a high need for this function in a department taking care of colorectal and anal cancer.

Effectiveness and Safety of Intracavernosal IncobotulinumtoxinA (Xeomin®) 100 U as an Add-on Therapy to Standard Pharmacological Treatment for Difficult-to-Treat Erectile Dysfunction: A Case Series

Registered pharmacological treatments are insufficiently effective for erectile dysfunction (ED) in around 30% of affected men. Intracavernosal injection (ICI) of ona- and abobotulinumtoxinA can reduce ED in insufficient responders. We aimed to assess the safety and effectiveness of incobotulinumtoxinA ICI as an add-on therapy to phosphodiesterase-type 5 inhibitors (PDE5-Is) or prostaglandinE1 ICIs (PGE1 ICIs) to treat ED that did not respond sufficiently to this treatment alone. We retrospectively analyzed data from 66 men with difficult to treat ED treated with single or repeated incobotulinumtoxinA 100U ICI as an add-on therapy. Response rate (increase in International Index of Erectile Function-Erectile Function domain score ≥ the minimum clinically important difference) was 52% (median (1st–3rd quartile) 43.5 (34–71) days post-incobotulinumtoxinA ICI). ED etiology (except spinal cord injury) and severity did not influence effectiveness. Only a clinically significant response to the 1st injection predicted a request for a 2nd injection (OR = 5.6, 95%, CI 1.6–19.4). Three men reported mild penile pain during the injection. These results provide preliminary evidence for the effectiveness and safety of incobotulinumtoxinA ICI as an add-on therapy to treat ED that is insufficiently responsive to standard care and provides support for the multicenter randomized clinical trial NCT05196308.

Systematic Review and Meta-Analysis of 16 Randomized Controlled Trials of Clinical Outcomes of Low-Intensity Extracorporeal Shock Wave Therapy in Treating Erectile Dysfunction

We conducted a meta-analysis to evaluate the efficacy of low-intensity extracorporeal shock wave therapy (LI-ESWT) in the treatment of erectile dysfunction (ED). From July 2011 to June 2021, we finally selected 16 randomized controlled trials (RCTs) including 1,064 participants to evaluate the efficacy of LI-ESWT in the treatment of ED from PubMed, EMBASE, and Cochrane databases. The data are analyzed by Review Manager Version 5.4. Fifteen articles mentioned International Index of Erectile Function (IIEF), in the follow-up of 1 month (mean difference [MD] = 3.18, 95% confidence interval [CI] = [1.38, 4.98], p = .0005), 3 months (MD = 3.01, 95% CI = [2.04, 3.98], p < .00001), and 6 months (MD = 3.20, 95% CI = [2.49, 3.92], p < .00001). After treatment, the improvement of IIEF in the LI-ESWT group was better than that in the control group. Besides, eight of the 16 trials provided data on the proportion of patients with baseline Erectile Hardness Score (EHS) ≤ 2 improved to EHS ≥ 3. The LI-ESWT group was also significantly better than the placebo group (odds ratio [OR] = 5.07, 95% CI = [1.78, 14.44], p = .002). The positive response rate of Questions 2 and 3 of the Sexual Encounter Profile (SEP) was not statistically significant (SEP2: OR = 1.27, 95% CI = [0.70, 2.30], p = .43; SEP3: OR = 4.24, 95% CI = [0.67, 26.83], p = .13). The results of this meta-analysis suggest that treatment plans with an energy density of 0.09 mJ/mm2 and pulses number of 1,500 to 2,000 are more beneficial to IIEF in ED patients. In addition, IIEF improvement was more pronounced in patients with moderate ED after extracorporeal shockwave therapy.

Outcomes and clinical predictors of extracorporeal shock wave therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome: a prospective randomized double-blind placebo-controlled clinical trial

OBJECTIVES

To report the one-year results of ESWT on CPPS patients and the possible clinical characteristics that may affect its efficacy.

PATIENTS & METHODS

A prospective randomized clinical study between January 2017 and January 2021 on 155 adult patients with chronic pelvic pain syndrome. All patients were initially evaluated with a thorough history and physical examination. Baseline symptoms evaluation of each participant was assessed using NIH-CPSI score, IPSS, VAS, and IIEF-5 score. Patients were randomized into two groups: a verum treatment group and a placebo treatment group. Patients of verum group in the lithotomy position received a perineally applied ESWT treatment once a week for four weeks with 3000 impulses each. Patients of placebo group received the same therapy head of the same device with a layer of air-filled microspheres to absorb the shock waves. The previously mentioned validated scores were reassessed on regular follow-up visits at one, three, six, and 12 months after the completion of ESWT.

RESULTS

A statistically significant improvement was noticed in the mean values of NIH-CPSI, IPSS, VAS, and IIEF-5 of the patients of verum group over the follow-up period with also statistically significant difference between both groups. At the first visit of follow-up after ESWT, 63 (82.8%) patients had ≥6 points decrease in the NIH-CPSI total score, while 13 (17.2%) patients did not. Univariate and multivariate analyses of the clinical characteristics between the responders and non-responders showed that those patients with history of psychological disorders or had higher initial NIH-CPSI score had a significantly lower response rate to ESWT (p = 0.005, 0.02 & p = 0.002, 0.004 respectively). ROC curve of NIH-CPSI score showed that a score of 32 was the cut-off point above which the response to ESWT decreased.

CONCLUSION

ESWT is an effective treatment option for CPPS. Its efficacy remained throughout long-term follow up. High initial NIH-CPSI score and history of psychological problems are significant predictors for it.

Analysis of the Impact of Clinical Factors on Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction

INTRODUCTION

Predictive factors for the treatment success of low-intensity extracorporeal shockwave therapy (Li-ESWT) for erectile dysfunction (ED) are still under debate.

METHODS

Li-ESWT was performed in 50 patients suffering from ED by applying 3,000 shock waves once a week over a period of 6 weeks. Treatment success was defined as an increase in the International Index of Erectile Function 5 (IIEF-5) score by ≥5 points or an Erectile Hardness Score (EHS) of ≥3 points. IIEF-5 and EHS were measured at baseline and at 3 and 6 months of follow-up.

RESULTS

Treatment success according to either the IIEF-5 score or EHS at any time of follow-up was achieved in 28 patients (56%). Twenty-five patients (50%) experienced an improvement during the first 3 months, which lasted for 6 months in 8 cases (16%). Three patients reported improved erectile function only after 6 months. When stratifying the cohort with regard to potential influencing factors, a significantly improved IIEF-5 score could be achieved in men with cardiovascular risk factors (p = 0.026) and in men with antihypertensive medication (p = 0.009). Men without cardiovascular risk factors showed no therapeutic benefit from Li-ESWT.

DISCUSSION/CONCLUSION

Li-ESWT is a valid but often short-lived treatment option for ED, especially in men with cardiovascular risk factors or controlled hypertension. Future studies should assess the feasibility and safety of repeated applications of Li-ESWT.

Efficacy and safety of avanafil as compared with sildenafil in the treatment of erectile dysfunction: A randomized, double blind, multicenter clinical trial

OBJECTIVE

To compare the efficacy and safety of avanafil as compared with sildenafil in the management of patients with erectile dysfunction.

METHODS

It was a prospective, randomized, double-blind, two-arm, active-controlled, parallel, multicenter, non-inferiority clinical study carried out in patients with erectile dysfunction for at least 3 months and International Index of Erectile Function - Erectile Function domain score of <26 at enrolment.

RESULTS

A total of 220 patients were randomized to receive either avanafil tablets 100 mg or sildenafil tablets 50 mg in 1:1 ratio. After 4 weeks of treatment, 40.0% of patients in the avanafil group and 45.6% of patients in the sildenafil group required dose escalation to a high dose (avanafil 200 mg/sildenafil 100 mg). The difference in the mean change of International Index of Erectile Function - Erectile Function score from baseline in the two groups increased from week 4 (1.1, 95% confidence interval -0.2 to 2.5) to week 8 (1.4, 95% confidence interval 0.1-2.7) and week 12 (2.1, 95% confidence interval 0.8-3.5), showing non-inferiority at week 4, and superiority at week 8 and week 12. Avanafil showed a faster onset of action as shown by a significantly better response to modified Sexual Encounter Profile 1 in the avanafil group (84.8%) as compared with that in the sildenafil group (28.2%; P < 0.001). Both avanafil and sildenafil were well tolerated by all the patients in the study; the most common adverse event reported during the study was headache in both the groups.

CONCLUSION

Avanafil is superior to sildenafil in improving the International Index of Erectile Function - Erectile Function domain score at the end of 12 weeks of treatment with the added advantage of faster onset of action.

Testosterone replacement therapy and erectile dysfunction

Testosterone (T) deficiency and erectile dysfunction (ED) are independently functionally and socially impairing, and their concurrence in men can be challenging to treat. Successful management requires an understanding of the mechanisms through which T underlies normal erectile function. While the literature elucidating some of these mechanisms is vast (e.g., androgen regulation of the activity of nitric oxygen synthase and phosphodiesterase type 5) for others it is scarce (e.g., catalysts of castration-induced corporal fibrosis). The randomized controlled trial data for the efficacy of T replacement as mono- or combination therapy to treat ED has been conflicting. Positive results were frequently not clinically meaningful. Meta-analyses have been helpful in illuminating trends that seem to be promising. Consensus is still lacking in several areas, such as the threshold of low T severity for which replacement therapy is most beneficial; the timing for initiating combination therapy; and the duration of treatment.

Adjuvant daily therapy with L-arginine 2,500 mg and tadalafil 5 mg increases efficacy and duration of benefits of low-intensity extracorporeal shock wave therapy for erectile dysfunction: A prospective, randomized, single-blinded study with 1-year follow-up

Purpose

To investigate a therapeutic protocol for erectile dysfunction (ED) based on the combination of low-intensity extracorporeal shock wave therapy (Li-ESWT), tadalafil, and L-arginine.

Materials and Methods

Recruited patients completed the International Index of Erectile Function erectile function domain (IIEF-EF) and the Erection Hardness Score (EHS) questionnaires at baseline and were randomly assigned in two groups: A (treatment group) and B (control group). Men in both groups received six weekly applications of Li-ESWT. Group A was prescribed adjuvant oral therapy with tadalafil 5 mg and L-arginine 2,500 mg. Follow-up visits were scheduled 1, 6, and 12 months after the last Li-ESWT application. At each follow-up visit, the IIEF-EF and EHS questionnaires were administered again. The main outcome measures were the changes from baseline to every follow-up visit in IIEF-EF and EHS scores.

Results

The mean IIEF-EF score in group A was 16.0±4.0, 24.8±3.4, 23.3±4.6, and 21.6±5.5 at baseline, 1, 6, and 12 months of follow-up, respectively, whereas in group B the mean IIEF-EF score was 16.5±4.1, 22.7±4.2, 21.5±4.5, and 19.5±4.9, respectively. We reported an increase in the mean EHS score in group A from 2.07±0.72 at baseline to 3.39±0.59, 3.17±0.67, and 2.98±0.72 at 1, 6, and 12 months, respectively, and in group B from 2.12±0.80 at baseline to 3.07±0.78 and 2.95±0.76 at 1 and 6 months, respectively.

Conclusions

Adjuvant daily therapy with L-arginine 2,500 mg and tadalafil 5 mg was safe and effective in increasing the efficacy and the duration of benefits of Li-ESWT.

The Efficacy of Li-ESWT Combined With VED in Diabetic ED Patients Unresponsive to PDE5is: A Single-Center, Randomized Clinical Trial

INTRODUCTION

Phosphodiesterase type 5-inhibitors (PDE5is) are the first-line treatment for patients with diabetes mellitus-induced erectile dysfunction (DMED), however, some patients are non-responser to PDE5is. We performed a perspective, randomized, comparative study to explore the efficacy of low intensity extracorporeal shock wave treatment (Li-ESWT) combined with vacuum erectile device (VED) in the treatment of DMED patients who were unresponsive to PDE5is.

METHODS

One hundred and five eligible patients were randomly divided into three groups: group A (VED), group B (Li-ESWT) and group C (VED plus Li-ESWT). Follow-up was conducted at 4 weeks, 8 weeks and 12 weeks after the end of treatment. The erectile function was estimated by the international index of erectile function-erectile function domain (IIEF-EF), erection hardness score (EHS), sexual encounter profile questions 2 and 3 (SEP2 and SEP3) and global assessment question 1 and 2 (GAQ1 and GAQ2) before and after treatment. The changes of five points in IIEF-EF were calculated as the minimal clinical important difference (MCID), which was considered as the main index of efficacy.

RESULTS

The MCID was achieved in 14.7%, 14.7% and 17.6% patients in group A at the follow up on 4 weeks, 8 weeks and 12 weeks, respectively (36.4%, 39.4% and 36.4% in group B; 36.4%, 51.5%, and 66.7% in group C). There were significant differences in the percentage of MCID cases between group A and group C at the follow up on 12 weeks (P<0.001), as well as that between group B and group C (P=0.014). Additionally, comparison in MCID within group C showed that there were significant differences between 4 weeks and 12 weeks follow-up (P=0.014).

CONCLUSION

Our findings indicated the combined therapy Li-ESWT and VED was more beneficial to shift turn PDE5is non-responders to responders for moderate patients with DMED than VED or Li-ESWT monotherapy. Moreover, this study provided evidence that patients with DMED who failed after taking oral PDE5is could attempt to opt for an alternative physicotherapy (Li-ESWT or VED) prior to more invasive alternatives.

Selecting an Individualized Treatment Approach: The Predictive Value of Erotic Stimulation and Nocturnal Erections for Efficacy of Tadalafil and Cure in Patients With Erectile Dysfunction

PURPOSE

This study aimed to evaluate two modes of Rigiscan for predicting tadalafil response, and to identify which Rigiscan variables are the most efficient at making these predictions.

METHODS

All patients received at least two rounds of nocturnal penile tumescence and rigidity (NPTR) testing and/or audiovisual sexual stimulation (AVSS), then completed the International Index of Erectile Function-5 (IIEF-5) questionnaire, followed by oral 5 mg tadalafil daily for 4 weeks. After a 4-week washout period, all respondents underwent an the IIEF-5 questionnaire again. ED patients were then categorized into tadalafil responders and tadalafil non-responders, who were then further divided into cured patients and uncured patients.

RESULTS

When predicting tadalafil responders, the area under the curve (AUC) of NPTR was superior to that of AVSS (0.68~0.84 VS 0.69~0.73), and the predicted optimal cut-off values were DOEE60≥17.75 min in NPTR, compared to other parameters regardless of AVSS or NPTR (P<0.05). When predicting which patients would be cured, the AUC of AVSS was superior to NPTR parameters (0.77~0.81 vs 0.61~0.76), and the determined best diagnostic cut-off values were DOEE≥4.125min in AVSS, compared to other parameters regardless of AVSS or NPTR (P < 0.05).

CONCLUSION

Rigiscan was able to predict the efficacy of daily tadalafil accurately and efficiently. Its diagnostic value was at maximum when DOEE60 ≥17.75 min of NPTR in tadalafil responders and DOEE ≥ 4.125 min of AVSS in cured patients.

Overall Sexual Function in Dysmetabolic Obese Men with Low Testosterone Levels Treated with Clomiphene Citrate

BACKGROUND

Sexual disorders are the most common clinical manifestations of hypogonadism. Functional hypogonadism is the most frequent form, and clomiphene citrate (CC) has been recently introduced as a possible off-label therapeutic option for these patients.

OBJECTIVES

This study aimed to evaluate the effects of CC on the overall sexual function in dysmetabolic obese men with low testosterone (T) levels.

METHODS

This was a sub-study of a randomized, double-blind, cross-over, placebo-controlled trial that included twenty-four obese or overweight subjects with impaired glucose tolerance or type 2 diabetes and confirmed low total T (≤10.4 nmol/l) levels. Subjects were treated with CC or placebo (Plac) for 12 weeks, with an interval wash-out period of 6 weeks between treatments. All subjects were on metformin 2gr/day and a low-calorie diet. The between-treatment difference in the overall sexual function was assessed by IIEF-15 and a qADAM questionnaire.

RESULTS

IIEF-15 and qADAM questionnaire data were available for 18 individuals. In unadjusted analyses, CC was associated with lower IIEF-15 total, erectile function, and intercourse satisfaction domain scores than Plac. After adjustments for multiple variables, CC was associated with a higher IIEF-15 sexual desire domain score (+0.9 ± 0.8; p<.001) despite a lower qADAM score (-2.1 ± 0.9; p=.008) with respect to Plac. No differences were found for the other domains between groups.

DISCUSSION

The clinical significance of the absolute changes in IIEF-15 and qADAM scores during CC versus Plac is limited. However, CC has a reliable effect on sexual desire and is also as safe as Plac. According to the sample size, duration of follow-up, and inclusion criteria defined for the main study, further studies are therefore needed to assess the long-term efficacy of CC.

CONCLUSION

Compared to Plac, CC was found to be associated with a neutral effect on overall sexual function.

Long Term Effectiveness and Safety of Intracavernosal Botulinum Toxin A as an Add-on Therapy to Phosphosdiesterase Type 5 Inhibitors or Prostaglandin E1 Injections for Erectile Dysfunction

BACKGROUND

Some evidence suggests that intracavernosal botulinum toxin A (BTX-A IC) injections administered in addition to phosphodiesterase type 5 inhibitors (PDE5-Is) or prostaglandin E1 intracavernosal injections (PGE1 ICI) could effectively treat erectile dysfunction (ED) in non-responders, or insufficient responders to these pharmacologic treatments.

AIM

To determine the long-term effectiveness and safety of combined treatment involving a single injection of BTX-A IC as an add on therapy to PDE5-Is or PGE1-ICI for the treatment of ED of different etiologies.

METHODS

A retrospective, uncontrolled, single center study was conducted. Data from 123 consecutive patients with ED who were insufficient responders to PDE5-Is or PGE1-ICI and who received onabotulinumtoxinA 100 U, abobotulinumtoxinA 250 U or 500 U IC as an add on to their current pharmacologic treatment were analyzed. All analyses were exploratory. Qualitative data were compared using the Fisher's exact test. Univariate and multivariate analysis were performed using logistic regression with Odds Ratios (OR). Only variables with P < .05 in the univariate analysis were selected for multivariate analysis.

RESULTS

The minimally clinically important difference (relative to baseline severity of ED) in the International Index of Erectile Function-Erectile function domain (IIEF-EF) score was achieved in 50% of patients at 34 (27-42) days and in 41% at 5.9 (3.9 - 8.1) months following BTX-A IC in combination with PDE5-Is or PGE1 ICI. The severity of ED influenced response to BTX-A IC according to the multivariate analysis (OR = 0.3, IC(95%]) = (0.16 - 0.56). Neither being post prostatectomy nor the type of BTX-A affected the response. Effectiveness tended to decrease more over time with abobotulinumtoxinA 250 U than 500 U.The only side-effects were mild penile pain on injection (n = 1) and mild penile pain for 3 days following injection (n = 1); no systemic effects were reported.

CLINICAL IMPLICATIONS

BTX-A IC (all types) administered as an add on to registered pharmacologic treatments improved erectile function for at least 6 months in 41% of patients with ED of varying etiologies, and was safe.

STRENGTHS & LIMITATIONS

A relatively large cohort of patients with ED was included, with a long follow-up period, however the study was retrospective, and uncontrolled.

CONCLUSION

This study provides preliminary evidence that BTX-A IC administered as an add-on therapy for ED that is insufficiently responsive to standard therapy is effective for at least 6 months, and is safe. Randomized clinical trials are now needed to fully confirm these results.

The Effect of Combination Treatment with Low-Intensity Shockwave Therapy and Tadalafil on Mild and Mild-To-Moderate Erectile Dysfunction: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial

BACKGROUND

Combination of different first-line treatments for erectile dysfunction (ED) has emerged as a promising therapeutic approach.

AIM

To conduct the first double-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy and safety of combination therapy with low-intensity shockwave therapy (LiST) and tadalafil vs LiST and placebo in patients with mild or mild-to-moderate vasculogenic ED.

METHODS

Fifty sexually active patients fulfilling the eligibility criteria were randomly assigned to 6 sessions of LiST twice weekly for 3 weeks and tadalafil (n = 25) or placebo (n = 25) once daily for 4 weeks. Patients were evaluated at 1, 3, and 6 months after completion of the treatment protocol.

OUTCOMES

The primary outcome was the mean change from baseline in the International Index of Erectile Function-Erectile Function (IIEF-EF) domain between the 2 groups at 3 months after treatment. Erectile function was also assessed at 1 and 6 months. The number of patients attaining a minimal clinically important difference (MCID) in the IIEF-EF, as well as the safety of combination therapy were evaluated.

RESULTS

Adjusting for the baseline values, IIEF-EF improved by 0.8 points more (95% confidence interval [CI] = -0.2 to 1.9, P = .12) at 1 month, 1 point more (95% CI = 0.1-1.9, P = .02) at 3 months and 1.7 points more (95% CI = 0.8-2.7, P < .001) at 6 months in patients treated with combination therapy compared to monotherapy. The number of patients attaining a MCID in the IIEF-EF between the 2 groups improved significantly only at the 3-month evaluation. No adverse events were reported during the whole study period.

CLINICAL IMPLICATIONS

Combination of LiST twice weekly for 3 weeks and tadalafil 5 mg once daily for 4 weeks may further ameliorate mild or mild-to-moderate vasculogenic ED compared to LiST monotherapy.

STRENGTHS & LIMITATIONS

We conducted the first randomized trial exploring the role of LiST and tadalafil in the management of ED. Conversely, our study lacks external validity due to its single-center design.

CONCLUSION

The addition of daily low-dose tadalafil during application of LiST may further improve erectile function compared to application of LiST as a standalone treatment in patients with mild or mild-to-moderate vasculogenic ED. Still, further high-quality studies are warranted to corroborate our findings.